Epilepsy

„Once sacred disease“

Milan Brázdil
1st Department of Neurology
Medical Faculty and St. Anne Hospital
Definition
 A chronic neurologic disorder manifesting by
repeated epileptic seizures (attacks or fits) which
result from paroxysmal uncontrolled discharges
of neurons within the central nervous system (grey
matter disease).

 The clinical manifestations range from a major

motor convulsion to a brief period of lack of
awareness. The stereotyped and uncontrollable
nature of the attacks is characteristic of epilepsy.
 Pathogenesis
 The 19th century neurologist Hughlings Jackson
suggested “a sudden excessive disorderly
discharge of cerebral neurons“ as the causation
of epileptic seizures.

 Recent studies in animal models of focal epilepsy

suggest a central role for the excitatory
neurotransmiter glutamate (increased in epi) and
inhibitory gamma amino butyric acid (GABA)
(decreased)
Epidemiology and course
 Epilepsy usually presents in childhood or
adolescence but may occur for the first time at any
age.

Newborns
Early school age
Adolescents
Seniors
Epidemiology and course
 5% of the population suffer a single sz at some
time
 0.5-1% of the population have recurrent sz =
EPILEPSY

 70% = well controlled with drugs (prolonged

remissions)
 30% epilepsy at least partially resistant to drug
treatments = INTRACTABLE
(FARMACORESISTANT) EPILEPSY.
Epilepsy versus epileptic
syndromes
Epilepsy is not a nosological entity – not one disease! Not unique aetiology...

Might be a symptom of numerous disorders – symptomatic epilepsy (TBI,

tumours, inflammation, stroke, neurodegeneration, ...)

Sometimes the cause remains unclear despite careful history

taking,examination and investigation!
Epilepsy - Classification
 The modern classification of the epilepsies is
based upon the nature of the seizures rather
than the presence or absence of an underlying
cause.

 Seizures which begin focally from a single

location within one hemisphere are thus
distinguished from those of a generalised
nature which probably commence in a deeper
structures (brainstem? thalami) and project to
both hemispheres simultaneously.
Epilepsy - Classification
 Focal seizures – account for
80% of adult epilepsies
- Simple partial seizures
- Complex partial seizures
- Partial seizures secondarilly
generalised

 Generalised seizures

 Unclassified seizures
Focal (partial) seizures
 Simple partial seizures
Motor, sensory, vegetative or psychic symptomato-
logy
Typically consciousness is preserved
Focal (partial) seizures
 Simple partial seizures
Motor, sensory, vegetative or psychic
symptomatology
Typically consciousness is preserved
Focal (partial) seizures
 Simple partial seizures
Motor, sensory, vegetative or psychic
symptomatology
Typically consciousness is preserved
Focal (partial) seizures
 Complex partial seizures (= psychomotor seizures)
Initial subjective feeling (aura), loss of
consciousness, abnormal behavior (perioral and
hand automatisms)
Usually originates in TL
Focal (partial) seizures
 Partial seizures evolving to tonic/clonic convulsions
– secondary generalised tonic/clonic seizures
(sGTCS)
Generalized seizures
(convulsive or non-convulsive)

 Absences
 Myoclonic seizures
 Clonic seizures
 Tonic seizures
 Atonic seizures
Generalized seizures

 Absences
 Myoclonic seizures
 Clonic seizures
 Tonic seizures
 Atonic seizures
Epilepsy
Differential Diagnosis
The following should be considered in the diff. dg. of epilepsy:
 Syncope attacks (when pt. is standing; results from global reduction
of cerebral blood flow; prodromal pallor, nausea, sweating; jerks!)
 Cardiac arrythmias (e.g. Adams-Stokes attacks). Prolonged arrest of
cardiac rate will progressively lead to loss of consciousness – jerks!
 Migraine (the slow evolution of focal hemisensory or hemimotor
symptomas in complicated migraine contrasts with more rapid
“spread“ of such manifestation in SPS. Basilar migraine may lead to
loss of consciousness!
 Hypoglycemia – seizures or intermittent behavioral disturbances may
occur.
 Narcolepsy – inappropriate sudden sleep episodes
 Panic attacks
 PSEUDOSEIZURES – psychosomatic and personality disorders
Epilepsy – Investigation
 The concern of the clinician is that epilepsy may be symptomatic of
a treatable cerebral lesion.
 Routine investigation: Haematology, biochemistry (electrolytes,
urea and calcium), chest X-ray, electroencephalogram (EEG).
Neuroimaging (CT/MRI) should be performed in all persons aged 25
or more presenting with first seizure and in those pts. with focal
epilepsy irrespective of age.
 Specialised neurophysiological investigations: Sleep deprived
EEG, video-EEG monitoring.
 Advanced investigations (in pts. with intractable focal epilepsy
where surgery is considered): Neuropsychology, Semiinvasive or
invasive EEG recordings, MR Spectroscopy, Positron emission
tomography (PET) and ictal Single photon emission computed
tomography (SPECT)
Epilepsy - Treatment
 The majority of pts respond to drug therapy
(anticonvulsants). In intractable cases surgery may be
necessary. The treatment target is seizure-freedom and
improvement in quality of life!
 The commonest drugs used in clinical practice are:
Carbamazepine, Sodium valproate, Lamotrigine (first line drugs)
Levetiracetam, Topiramate, Pregabaline (second line drugs)
Zonisamide, Eslicarbazepine, Retigabine (new AEDs)
 Basic rules for drug treatment: Drug treatment should be
simple, preferably using one anticonvulsant
(monotherapy). “Start low, increase slow“.
Add-on therapy is necessary in some patients…
Epilepsy – Treatment (cont.)
 If pt is seizure-free for three years, withdrawal of
pharmacotherapy should be considered. Withdrawal
should be carried out only if pt is satisfied that a further
attack would not ruin employment etc. (e.g. driving
licence). It should be performed very carefully and slowly!
20% of pts will suffer a further sz within 2 yrs.
 The risk of teratogenicity is well known (~5%), especially
with valproates, but withdrawing drug therapy in
pregnancy is more risky than continuation. Epileptic
females must be aware of this problem and thorough
family planning should be recommended. Over 90% of
pregnant women with epilepsy will deliver a normal child.
Epilepsy – Surgical Treatment
 A proportion of the pts with intractable epilepsy will
benefit from surgery.
 Epilepsy surgery procedures: Curative (removal of
epileptic focus) and palliative (seizure-related risk
decrease and improvement of the QOL)
 Curative (resective) procedures: Anteromesial temporal
resection, selective amygdalohippocampectomy,
extensive lesionectomy, cortical resection,
hemispherectomy.
 Palliative procedures: Corpus callosotomy and Vagal
nerve stimulation (VNS).
Status Epilepticus
 A condition when consciousness does not return
between seizures for more than 30 min. This state may
be life-threatening with the development of pyrexia,
deepening coma and circullatory collapse. Death
occurs in 5-10%.
 Status epilepticus may occur with frontal lobe lesions
(incl. strokes), following head injury, on reducing drug
therapy, with alcohol withdrawal, drug intoxication,
metabolic disturbances or pregnancy.
 Treatment: AEDs intravenously ASAP, event. general
anesthesia with propofol or thipentone should be
commenced immediately.